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SECTION 3: Overview of the Independent Clinical Review Process

The purpose of this section is to provide a more detailed overview of the stages and roles in the Independent Clinical Review Process (ICR). It is laid out in chronological order, from the start of the process when a family requests a review, to the possible outcomes.

Stages in the Clinical Review Process

The OAP Provider sends the case file to the ICR Coordinator

As outlined in the OAP Guidelines, a family and provider must first work with their DSO or DFO OAP provider, through the providers’ internal review process, to attempt to reach agreement about a child’s Behaviour Plan. Independent reviews can be launched when a family is dissatisfied with their child’s OAP Behaviour Plan and with the outcome of their provider’s internal review process, or if they are dissatisfied with their newly updated OAP Behaviour Plan following an ICR review and the outcome of their provider’s internal review process of that plan. If the family remains dissatisfied with the outcome of the OAP provider’s internal review, they can request an independent review of their child’s OAP Behaviour Plan by completing a Family Request Form available from their OAP provider as well as the ICR Coordinator's website. The family signs and submits the form to their DSO or DFO OAP provider. The Family Request Form provides an opportunity for families and their children to outline their concerns with the plan. For the purposes of the ICR, the term “family perspective” is used and it includes both the family’s and child’s perspectives.

At any point during the ICR, a family can choose to withdraw from the process and continue with their original OAP Behaviour Plan.

Within 5 business days of receiving an ICR Family Request Form, the OAP provider reviews the child’s case file, working with the family to complete it. At this time, families can add supporting documentation to the case file. Once the file is complete, the OAP provider sends it to the ICR Coordinator.

The ICR Coordinator sends the case file to the Review Committee

Within 10 business days of receiving a child’s case file materials, the ICR Coordinator de-identifies it so all information that could identify the child, the family and the provider is removed, assigns it to a Review Committee and sends the case file to that Review Committee. The ICR Clinical Reviewers review the case file in preparation for the Clinical Review Meeting, and the Family Representative reviews the case file to help provide a clear understanding of the family perspective.

If the Clinical Reviewers identify gaps or inconsistencies in the clinical data in the case file and want clarification, they can reach out to the ICR Coordinator to request follow up information from the OAP Clinical Supervisor (for example, by sending questions to the OAP Clinical Supervisor). The ICR Coordinator acts as an intermediary between the key players in a review to protect confidentiality and independence.

The Family is contacted

Within 5 business days of sending the case file to the Review Committee, the ICR Coordinator arranges a first-name-basis conference call between the Family Representative and the family to review the family’s concerns with their child’s OAP Behaviour Plan, as specified in the ICR Family Request Form. To mitigate against conflicts of interest and protect privacy, the ICR Coordinator will only assign a Family Representative to a family from a region in the province other than their own (see Appendix 6.1 for map).

In some instances, families may request additional time to be contacted and arrange for the conference call. Any additional time requested by families in the review process will have an impact on ICR timelines as outlined in these ICR Guidelines, and could delay when a family receives an ICR decision.

In the interest of preserving the privacy of all parties involved, every attempt is made by the family and Family Representative to maintain anonymity and a collaborative working relationship. As such, any contact between the family and the Family Representative is arranged through the ICR Coordinator, and no personal contact information is to be shared between the family and Family Representative.

Verification and Confirmation of the Family Perspective

During this conference call, the Family Representative reviews the Family Request Form to confirm that no information is missing, and adds additional remarks as requested by the family. The goal is to help provide a clear and accurate understanding of the family perspective, and make sure this information can be presented to the Clinical Reviewers within a reasonable timeframe (approximately 30 minutes). The Family Representative completes the Family Perspective Form to include the finalized version of the family perspective. Any changes or additions to the form are confirmed with the family during the conference call.

Planning for the Presentation of the Family Perspective
The Family Representative is, by default, responsible for presenting the family perspective to the Clinical Reviewers during the Clinical Review Meeting. However, during the conference call, the Family Representative gives the family the option of presenting the family perspective instead.

The family has up to 5 business days to determine whether they wish to present the family perspective directly to the Review Committee members, provide the name of the family member who will present, and complete a Family Perspective Waiver available through the ICR Coordinator's website. The family submits the signed waiver to the ICR Coordinator confirming that they understand that this may result in a loss of anonymity to the reviewers. If this step is not finalized within this timeframe, the Family Representative presents the family’s perspective to the Clinical Reviewers.

The Family Representative finalizes the Family Perspective Form

Irrespective of whether or not the family chooses to present their perspective to the Clinical Reviewers, the Family Representative has 5 business days following the phone call with the family to finalize the Family Perspective Form. This document contains the family’s perspective as it will be presented to the Clinical Reviewers, either by the Family Representative or a family member. The Family Representative sends the Family Perspective Form to the ICR Coordinator to be shared with the family and the Clinical Reviewers.

The family has the opportunity to provide supplementary comments on the form to the ICR Coordinator if they are dissatisfied with the final version. These supplementary comments are also added to the case file materials which the Clinical Reviewers review.

The Clinical Review Meeting

Within 15 business days of sending the case file material, the ICR Coordinator arranges for a Clinical Review Meeting conference call. This meeting gives families the opportunity to have the family perspective outlined to the Clinical Reviewers. It also allows the Clinical Reviewers to deliberate and discuss the case file materials and reach a decision about the child’s Behaviour Plan based on consensus.

The Clinical Review Meeting involves two stages. The first stage, attended by all members of the Review Committee, is dedicated to outlining the family perspective to the Clinical Reviewers. Families are also invited to join at this stage of the meeting, should they choose to do so. The second stage is dedicated to a discussion of the case file materials, and to making a decision about the Behaviour Plan. Only the Clinical Reviewers are involved in this stage.

Stages in the Clinical Review Meeting
Stages Attending Active Participant(s)
1. Presenting the Family Perspective
  • Review Committee;
  • The Family (optional).
  • 1 person identified to present the family perspective (either Family Representative or a family member).
  • Clinical Reviewers.
2. Deliberation and Clinical Decision-Making
  • Clinical Reviewers.
  • Clinical Reviewers.

Stage 1: Presenting the Family Perspective
Approximately 30 minutes is allotted at the Clinical Review Meeting for the presentation of the family’s perspective, as outlined in the Family Perspective Form, by the Family Representative or a member of the family requesting the review, to the independent reviewers. The ICR allows for more time to present the family perspective in the event a family needs special accommodation. The Family Representative and ICR Coordinator are responsible for ensuring that the family perspective is effectively presented. The ICR Clinical Reviewers will not provide feedback to the families at this time.

This stage concludes once the family perspective has been shared.

Stage 2: Deliberation and Clinical Decision-Making
Following the presentation of the family perspective, the Clinical Reviewers reconnect, allowing them to proceed to the second stage of the Clinical Review Meeting. This stage involves a clinical discussion about the case file materials and the Behaviour Plan to determine whether or not the plan is consistent with the case file materials and evidence-based practice. For more information about the peer-reviewed decision-making, please refer to section 2 Peer-Reviewed Decision-Making in this document.

The Clinical Reviewers work towards reaching a consensus decision about whether to accept the Behaviour Plan or to send it back to the OAP Clinical Supervisor for revision and/or more information.

Decision is written and sent to the ICR Coordinator

ICR Clinical Reviewers have 10 business days from the date of the Clinical Review Meeting to develop and provide a written decision. Decision-making in the ICR is informed by:

ICR decisions are based on a consensus between the two Clinical Reviewers to either accept the OAP Behaviour Plan or send it back to be revised or for additional information.

A) Steps Toward Reaching Consensus
In the event that Clinical Reviewers cannot achieve consensus on a decision, they will send the OAP Behaviour Plan back to the OAP Clinical Supervisor, through the ICR Coordinator, to address their areas of concern. The Clinical Reviewers complete the ICR Decision Form, including an explanation in the rationale section which outlines the areas of concern or gaps which need to be addressed by the OAP Clinical Supervisor. Once complete, the Clinical Reviewers forward the ICR Decision Form to the ICR Coordinator who will send it to the OAP Clinical Supervisor.

The OAP Clinical Supervisor has 15 business days from the day they receive the ICR Decision Form to meet with the family to discuss addressing the Review Committee feedback and provide the ICR with a firm date for when the revised OAP Behaviour Plan will be re-submitted for a decision.

After addressing the Clinical Reviewers’ feedback, the OAP Clinical Supervisor re-submits the revised OAP Behaviour Plan to the ICR Coordinator, who will share it with the same Clinical Reviewers for a decision.

B) A Decision is Reached
Consensus can be reached to accept the OAP Behaviour Plan as is, or direct it back to the OAP Clinical Supervisor to address areas of concern in the Behaviour Plan. Decisions reflect the view of both Clinical Reviewers.

The OAP Behaviour Plan is Accepted
The Clinical Reviewers may, after careful consideration of the family perspective and a clinical review of the case file materials, decide to accept the OAP Behaviour Plan as is. Using the ICR Decision Form, they provide a clear rationale, in writing, specifying which key elements of the plan were reviewed (based on the OAP Clinical Framework).

The Clinical Reviewers summarize the case file material reviewed and the process used to review assessment data for each element in an OAP Behaviour Plan identified as an area of concern by the family on the Family Perspective Form. The reviewers also explain the underlying reasons for their decision to accept the plan. The Clinical Reviewers provide as much detail as possible in their rationale, based on the concerns originally raised by the family, to help the family and OAP Clinical Supervisor understand why the plan was accepted.

Once complete, the Clinical Reviewers forward the ICR Decision Form to the ICR Coordinator.

The OAP Behaviour Plan is Directed Back for Revisions and/or More Information
The Clinical Reviewers may, after careful consideration of the family perspective and a clinical review of the case file materials, decide to send an OAP Behaviour Plan back to the OAP Clinical Supervisor for revisions and/or more information. Using the ICR Decision Form, the reviewers provide a clear rationale, in writing, specifying which key elements of the plan were reviewed (based on the OAP Clinical Framework). The Clinical Reviewers provide as much detail as possible in their rationale, based on the concerns originally raised by the family, to help the family and OAP Clinical Supervisor understand what areas in the plan require revision and/or further clarity.

Since reviewers base their decisions on a paper-based clinical review of the case file materials, and discussions at the Clinical Review Meeting, it is not appropriate for them to ‘re-write’ existing Behaviour Plans or prescribe what should be included in a revised plan. Clinical Reviewers do not make clinical recommendations about what services a child should receive, the number of service hours or the duration of service. Rather, they highlight areas of concern in the plan, and indicate where greater clarity and/or data is required.

The decision is sent to the Family and OAP provider

The ICR Coordinator has 5 business days from the day they receive a decision from the Review Committee Clinical Reviewers to send it to the family and the OAP provider. The family and OAP provider are encouraged to work together to address any issues raised by the independent reviewers. The family’s OAP Family Support Worker will have access to the ICR decision through the child’s OAP case file, and will offer to discuss the decision with the family if the family so chooses.

Steps after a Decision is Rendered

The OAP Behaviour Plan is Accepted
If the ICR decision is to accept the OAP Behaviour Plan, the OAP provider and the family work together to implement the plan. If implementation of the plan had already begun, the date of the child’s next regular progress review does not change.

The OAP Behaviour Plan is Directed Back for Revisions and/or More Information
If the ICR decision requires that the plan be sent back to the OAP Clinical Supervisor for revisions and/or more information, the provider has 15 business days from the day they receive the decision to, in collaboration with the family, update, finalize and implement the plan. The new plan must address the concerns or issues highlighted by the Clinical Reviewers in their decision. If implementation of the previous plan had already begun, the time spent during the ICR does not count as part of the service period and the child’s next regular progress review is deferred by that length of time.

Reviewing the Revised OAP Behaviour Plan

If a revised plan is accepted by the family, the OAP provider and the family work together to implement the plan. The plan is monitored and updated at regular intervals as outlined in the OAP Guidelines and the Clinical Framework.

If the family and OAP provider cannot reach consensus on the revised plan, the family has the option to request a second review of the revised plan. In order to maintain independence and impartiality throughout the review process, the ICR Coordinator will assign a new Review Committee for the second review.

If the Clinical Reviewers do not accept the second plan and direct it back to the OAP Clinical Supervisor for further changes, the OAP Clinical Supervisor and the family have 15 business days after receiving the final ICR decision to update, finalize and implement the plan based on the feedback provided by the Clinical Reviewers.

The plan will be reassessed at the child’s next regular progress review, as per the OAP Guidelines and Clinical Framework.

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